NSG 310 Foundations Exam III Blueprint Spring 2020

NSG 310 Foundations Exam III Blueprint Spring 2020 Med Math – 6 Po meds Sliding Scale Insulin Oxygenation and Perfusion – 12 Orthopnea –difficulty breathing while lying down- typically in obese, COPD, heart failure, and pregnant women Hypoxia- inadequate tissue oxygenation at the cellular level, life threatening, causes: anemia, carbon monoxide poisoning, septic shock, cyanide poisoning, pneumonia atelectasis, cardiomyopathy, spinal cord injury, head trauma. Sign and symptoms: rapid pulse, rapid shallow respirations, dyspnea, increased restlessness or light headedness, nasal flaring, substernal or intercostal retractions, cyanosis, anxious, tired, leaning forward, fatigue, lethargy, clubbing Hypoxemia- inadequate oxygen levels in the blood Respiratory assessment • Assess for risk factors • Physical Exam: Assess pain, fatigue, dyspnea, rapid pulse, rapid respirations, nasal flaring, substernal or intercostal retractions, cyanosis, breathing patterns, cough, • Diagnostic testing: blood oxygenation, lab test, cardiac monitoring, spirometer, sputum sample Suctioning and follow-up assessment When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure. Convey your findings verbally during nurse-to-nurse shift report and to the interdisciplinary team during daily rounds. Oxygen therapy- Medication ordered by a physician, used to relieve or prevent hypoxia, may be administered by nurse in an emergency situation, Safety issues (flammability, humidification, transporting tanks), room air is 21%, sign needs to be places saying keep 10 ft away from open flame, no smoking, secure cylinders, grounded equipment so no sparks, check tank levels before transporting Methods: Nasal cannula or prongs: ¼-6 LPM, 23-45% O2 Face Mask: simple: 6-8 LPM, 40-50% O2 Partial rebreather: 6-15 LPM, 50-80% O2 Non-rebreather: 6-15 LPM, 70-100% O2-physical trauma, smoke inhalation, CO poisoning Venturi: vent weaning, COPD patients Face tent: facial trauma, claustrophobia, vent weaning Oxyhood/oxygen tent Role of carbon dioxide as a driver to breathe Increasing Levels of CO2 in the blood drives the stimulus to breathe. Neurons in the respiratory center in pons and medulla respond to the increase of CO2 of H+ ions. Factors that positively and negatively affect circulation and perfusion • Advanced age- with increased age= decreased elasticity, decreased exchanged air, decreased reflexes; drier mucous membranes, diminished muscle strength, decreased chest expansion, decreased immune function, increased risk of GE reflux to aspiration calcification of valves, SA node; atherosclerosis, osteoporosis changes in thorax; calcification of airways. Alveoli enlarge, decreased surface area for gas exchange, decreased functional cilia so decreased cough mechanics and increased risk for respiratory infections, fib • Lifestyle: nutrition (risk for anemia, muscle wasting, increased CO2 retention with high carb diets), exercise, smoking, substance abuse, stress, pregnancy • Occupation • Health Status • Meds • Stress – hyperventilation • Pollution • Altitude – decreased pO2 in air Types of airways and suctioning and when each is used Oropharyngeal and nasopharyngeal: used when the client can cough effectively but is not able to clear secretions YanKauer Suction Catheter: for the mouth, not the nose Orotracheal and nasotracheal: used when the client is unable to manage secretions in lower airways Tracheal: Used with an artificial airway Trach care 1. Position patient in semi-Fowler’s position and place a towel or linen-saver pad over the patient’s chest. 2. Don clean gloves. 3. Hyperoxygenate the patient as needed, and suction the tracheostomy. 4. Remove and discard the soiled tracheostomy dressing in the appropriate receptacle, and then remove and discard your gloves. Perform hand hygiene. 5. Place the tracheostomy care equipment on the bedside table, and prepare equipment, using sterile technique. 6. Don sterile gloves. 7. For patients receiving oxygen with your non-dominant (nonsterile) hand, remove the oxygen or humidification source. Attach the oxygen source to the outer cannula, if possible. If not possible, have the respiratory therapist set up oxygen blow by to use while you are cleaning the reusable inner cannula. 8. Unlock and remove the inner cannula with your non-dominant hand, and care for it accordingly. 9. If using disposable inner cannula, dispose of the inner cannula in the biohazard receptacle according to agency policy. You should never clean and reuse a disposable inner cannula. With your dominant hand insert the new inner cannula into the patient’s tracheostomy in the direction of the curvature. Following the manufacturer’s instructions, lock the inner cannula in place securely to prevent it from dislodging. Remember to keep your dominant hand sterile. 10. For reusable inner cannula, place it in a STERILE basin filled with hydrogen peroxide with your nonsterile hand, and scrub it with the sterile nylon brush, using your sterile dominant hand. Immerse the inner cannula in the container of sterile normal saline solution and agitate it until is rinsed thoroughly. Tap the inner cannula against the side of the container. With your dominant hand, reinsert the inner cannula into the patient’s tracheostomy in the direction of the curvature. Following the manufacturer’s instructions, lock the inner cannula in place securely to prevent it from dislodging. Remember to keep your dominant hand sterile. 11. Clean the stoma under the faceplate with cotton-tip applicators saturated with sterile normal saline solution, using a circular motion from the stoma site outward. Use each applicator only once, and then discard it. 12. Clean the top surface of the faceplate and the skin around it with the gauze pads saturated with sterile normal saline solution. Use each gauze pad only once, and discard it. 13. Dry the skin and outer cannula surfaces by patting them lightly with the remaining dry gauze pad. Professional Communication/Documentation – 10 Professional Standards of Care pg 372 Factual/relevant Complete/current Organized/concise Diagnosis Plan and Expected outcomes Implementation Coordination of Care- collaborating with other professionals to ensure the best overall care Evaluation Standard abbreviations Subjective data use quotes No blank lines or spaces, black ink Only chart for yourself Avoid: vague terms, opinions, judgment, jargon Source Oriented record systems Patients in hospitals and long term care facilities receive care from a variety of disciplines and is put into a record. A typical source-oriented record includes the following sections: Admission data: demographic info, insurance data, contact info Advance directive: info on clients wishes for the extent of care and medical support that should be given in the event of a life-threatening situation History and physical: a detailed summary of the current health problem; past medical; surgical and social history; medications taken; allergies; review of systems, and physical examination Provider’s orders: orders for medications, treatments, and activities Progress notes: chronological charting by healthcare team members including patient exams, problem identification, and patient’s response to therapy Diagnostic studies: reports detailing the findings of test that have been performed, such as xray exam, ultrasound, or pulmonary function tests Laboratory data: results from diagnostic tests such as complete blood count Nurses notes: documentation of patient care and response to treatment recorded by nurses Graphic data- numerical data collected over time and displayed visually to allow analysis of trends. Examples include intake and output records, vital sign flow sheets, rating scales, and checklists regarding patient activity, dietary intake, and ADL task Rehabilitation and therapy notes- chronological charting by therapist about assessments, treatment plan, and patient response to therapy Discharge planning: includes data from utilization review, case managers, or discharge planners on anticipated client needs after discharge Advantages: can easily find the care provided by each discipline and results of lab and diagnostic test Disadvantages: info can be scattered, hard to track treatment and patient outcome Medication administration record and terminology for medication administration times Def: contain information about the medications that have been prescribed for a client. Format and info may vary by outpatient and inpatient facilities. Outpatient typically contains info on how to use the meds prescribed, inpatient contain a list of prescribed and track med admin and usage for the agency. Med Admin times: • Scheduled meds- meds that are to be given on a regular basis • Unscheduled meds- meds are to be given on call at the appropriate times • Continuous infusion- iv fluids that are running continuously unless stopped for a blood transfusion or to give an iv med that is not compatible with the iv fluid running • PRN- as needed • STAT- now and only gave one • Single-order- med given once at a prescribed time, but not necessarily immediately. Charting additional info about medication administration • Injections- if you give this, must chart type and site to protect patient from repeated injections in same sight • Assessment required before administration- some meds require a specific assess. Before admin meds to ensure it is safe to give, you must document that data on the MAR along wit h time of admin and other required info • STAT, prn, Unscheduled, and Single order meds- enter time given, note assess findings, patient response • Patient refusal- if patient refuses med, note refusal • Omitted meds or delayed admin- document why meds was held or given at a diff time Verbal and telephone orders For change in condition (ancillary, provider) Lab and diagnostic reports To another facility or care giver in a different environment Must be: Clear Accurate Documented – who, what, when, read back critical information: every conversation! Preop checklist from PP Advanced Directives from PP • If something was to happen to you, what kind of care would you like to receive EX: living will, medical power of attorney Documentation of nursing interventions Handoff Report and Reporting events SBAR/ ISHAPED Nurse to nurse at end of shift Primary care office to unit Long term care facility to unit ER to unit Unit to procedural area OR or procedural area back to unit Unit to unit Unit to long term care facility Structured/Organized SBAR: situation, background, assessment, recommendation S (Situation): Peer introduced him/herself to the physician, calling about ____ (patient’s name and room number), calling because____(brief statement regarding the problem, when it started, severity, etc.). B(Background): Reason for admission, Complete vital signs, LOC, pertinent assessment findings, other information, such as current medications, laboratory results, code status, etc. A(Assessment): Peer stated what was believed to be the problem, or identified some degree of concern or possibilities as to troubleshooting. R(Recommendation): Peer stated what they would like done, such as when to call physician back, requesting a consult, possibility of HCP coming to evaluate patient condition, transfer to another unit, etc. ISHAPED: introduction, story, history, assessments, plan, error prevention, dialogue Faculty or unit specific Lateral violence: deliberate and harmful behavior demonstrated in the workplace by one employee to another Nutrition and Enteral Tubes – 12 Fiber, and Nutrients High Fiber Foods:  Grains  Whole wheat pasta – spaghetti cooked 6.3 grams  Pearled barley – 1 cup cooked 6.0 grams  Oat bran – 1 cup cooked 6.0 grams  Quinoa or oatmeal – 1 cup cooked 4.0 grams  Legumes  Split peas – 1 cup boiled 16.3 grams  Lentils – 1 cup boiled 15.6 grams  Black beans – 1 cup cooked 15.0  Vegetables  Artichokes – 1 medium 10.3 grams  Green peas – 1 cup 8.8 grams  Broccoli -1 cup boiled 5.5 grams  Turnip greens – 1 cup boiled 5.0 grams  Brussel sprouts – 4.1 grams  Fruits  Raspberries – 1 cup 8.0 grams  Pears – 1 with skin 5.5 grams  Apple – 1 medium with skin 4.4 grams Carbohydrates Starches and sugars Supply energy Simple, complex, dietary fiber Choose carbs from whole grains vegetables and legumes: barley, rye, quinoa, cold cereal, apple, pear, berries, dark leafy greens, sweet potatoes, celery, asparagus, black beans Choose carbs high in fiber Proteins Amino acids- 8 essential, animal sources are complete Need 0.8 grams of protein per each kg High levels-osteoporosis Low levels- failure to thrive, muscle wasting, weakened immune system Fats Saturated, monounsaturated, and polyunsaturated Limit saturated and trans Increase omega 6 and 3: plant oils such as olive, coconut, grapeseed, nut oils, fish Water Cells depend on a fluid environment Vitamins Essential to metabolism Water or fat soluble Minerals Catalysts for biochemical reactions Lactose intolerance, gluten intolerance vs. allergy • Lactose intolerant: The inability to fully digest sugar (lactose) in dairy products • Gluten intolerant: (celiac disease) An immune reaction to eating gluten, a protein found in wheat, barley, and rye. • Allergy: An unpleasant or dangerous immune system reaction after a certain food is eaten. Different types of enteral tubes • Salem sump tube o Double lumen, blue port allows air into stomach o Large bore, used for gastric lavage • Levin Tube o Single lumen with holes o Also used to drain stomach contents • Nasoenteric NE is similar to an NG tube except that it is longer than an NG tube, extends into the duodenum or jejunum • Percutaneous gastrostomy (PEG) tube is placed surgically or laparoscopically through the skin and abdominal wall into the stomach or jejunum (PEJ). • Low-profile gastrostomy tube (G-button) is often used for patients, especially pediatrics, requiring long-term enteral feedings. Tube feedings troubleshooting Nausea & Vomiting Description: abdominal distress, distention, feeling bloated, cramping, vomiting, dry heaves, retching, cold sweat. Immediate action: stop feeding! Diarrhea Description: abdominal pain or cramping with frequent, loose, and/or watery stool. Immediate action: decrease volume or rate of tube feeding. Constipation Description: infrequent and/or hard stool, bloating, gas, cramping, or pain. Immediate action: increase fluid intake. Tube Displacement Description: tube has come out of body or has moved out of place…choking, difficulty breathing, nausea/vomiting, abdominal pain, diarrhea. Immediate action: discontinue feeing! Tube Obstruction/Blockage Description: inability to flush with water, infuse tube feeding or administer medication, bulging of tube when feeding or flushing. Immediate action: make sure the tube clamp is open, do not force, try to flush with syringe of warm water. Aspiration Description: vomiting, heartburn, coughing or choking with difficulty breathing, chest pain, possible fever, shortness of breath, pneumonia Immediate action: stop feeding! Aspiration prevention and tube feeding Keep patient’s head above 30 degrees. Tube feeding residuals Refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding. Teaching patients about low sodium diet • Often prescribed with renal diseases and cardiovascular diseases • Sodium amount may be specified, example 2000 mg/day or than 1500 milligrams/day • Teach patients which foods are high in sodium: processed and pre-prepared foods, some condiments, canned soups, cheeses, pickles, bread • Strategies to lower sodium intake: avoiding fast foods and processed foods, using herbs instead of salt to season food, avoid using the salt shaker once food has been prepared, salt alternatives such as Mrs. Dash, avoid processed meats, read nutrition labels. • Dietary Approach to Stop Hypertension (DASH diet) increase vegetables, fruits, and whole grains, limit red meats, sodium, sweets, saturated fats, sugary drinks. Lower sodium and increasing nutrients such as magnesium, calcium, and potassium aids in lowering blood pressure Different types of diets vegan, vegetarian, kosher • Vegan: excludes all meat and animal products • Vegetarian: All vegetarian diets exclude red meat and poultry • Kosher: based on Jewish law, pig and camel always avoided, can have meat and fowl but has to be butchered in a quick and painless way, produce must be inspected, meat and fowl cannot be eaten in the same meal as dairy products, utensils are used for only specific kosher items Bowel Elimination – 10 Antibiotics and the gut strategies to prevent C-diff and other GI disturbance Probiotics! Stoma physiology and stoma care – know the gut what kind of drainage from what king of ostomy and care of each type At each interaction with the patient: Assess: condition of the stoma, condition of the peristomal skin, stomal output, bridge/stents/peristomal sutures ● Check appropriate appliance is in correctly and is secure ● Provide adequate supplies of suitable appliance ● Provides appropriate template according to size and shape of stoma Teach patient/care giver to become competent at an appliance change prior to discharge, including preparation, pouch emptying, pouch renewal, skin care, disposal and the importance of hand washing. Discuss implications of stoma on lifestyle with patient/care giver including: dietary issues, rectal discharge, hygiene, physical activity, sexuality Address patient’s need for psychological support in relation to the change in body image. Evaluate and document all interactions and liaise with relevant health care professionals. Laxatives, Suppositories and Enemas nursing procedures to administer  Sims position - inserting suppositories & flatulence tubes, administering enemas, digital removal of fecal impaction  Drape patient for privacy  Have patient practice deep breathing exercises to help them relax  Generous use of lubricant Bowel sounds and nursing assessment and interventions Take a few minutes to compose a health history interview question you could use to assess bowel function.  Interview patient to find out what is normal for them  Ask about color, consistency, shape/size  Ask if there have been any recent changes in bowel habits or stool  Ask if the patient has a history of elimination problems  Current medications – many drugs can cause constipation, does the patient currently take any drugs to help with elimination?  When was his last BM  If they have an ostomy, ask how they care for it – what type of appliances, adhesives, skin prep, etc. do they use, frequency of emptying bag, frequency of changing bag, whether or not they irrigate Order of assessment is important 1. Inspection 2. Auscultation 3. Percussion 4. Palpation  Color  Stoma size and shape  Stoma bleeding  Peristomal skin condition  Amount and type of feces  Patient sensations Impaction, and Paralytic Ileus what are the differences why do they occur and what care will the patient need Fecal Impaction: Definition: A mass of hardened, stool in the rectum (can extend higher) which the client cannot pass  Leaking liquid stool  Causative / Contributing factors  Treatment interventions  Digital removal (techniques and cautions)  Enemas Paralytic ileus Definition: obstruction of the intestine due to paralysis of the intestinal muscles. The paralysis does not need to be complete to cause ileus, but the intestinal muscles must be so inactive that it prevents the passage of food and leads to a functional blockage of the intestine. Factors that affect normal bowel elimination  Developmental – elimination patterns change throughout the lifespan  Stress – affects motility of GI tract, can cause diarrhea or constipation  Diet – regular eating schedule, fiber intake, foods that increase or decrease peristalsis  Dietary supplements – ex. magnesium → loose stools, calcium→ constipation  Fluids – adults need 1,500-2,000 ml water/day, excessive intake of sugary drinks (loose stools), dehydration or milk (constipation)  Activity – stimulates peristalsis, inactivity → constipation  Medications – many can slow or increase peristalsis, ex. antacids, iron, opioids, laxatives  Surgery and Procedures – anesthesia, stress, manipulation of the bowel during surgery, decreased mobility, surgeries involving perineal or anal region  Pregnancy – uterus expands → displaces intestines, increased progesterone slows motility, constipation & hemorrhoids common  Pathological conditions – neurological disorders, food allergies, food intolerances, diverticulosis Nursing interventions to promote healthy bowel habits  Encourage fluid intake (X ml per day)  Provide high-fiber foods  Teach patient which foods are high in fiber  Document BMs each day  Provide privacy during times when patient normally defecates  Encourage mobility, exercise  Timing: response promptly to call bells, urge for BM often occurs after eating or drinking coffee Digital removal of impactions  Rectal tube for flatulence  Enemas  Fecal incontinence pouch  Medications – laxatives, anti-diarrheal, anti-flatulent  Skin care, especially with incontinence and ostomies  Teach hand hygiene  Monitor fluid and electrolyte balanc